As I work with pharma companies, I'm often asked "When will we get major reform of the healthcare system?" and "What will the reformed system look like?" And sometimes "How will we get there?" This is not the same as asking "How should we reform the system?" Or "What should a reformed system look like?"

Healthcare reform is already a major issue in the run-up to the 2008 elections; in our latest polls, it is second only to the war in Iraq. But the forces aligned against reform are so strong that it may be years before we see more than incremental changes.

The healthcare system is changing rapidly, with or without reform, as health information technology, evidence-based medicine, practice protocols, and pay-for-performance all play larger roles. Major healthcare reform is focused on more fundamental issues, primarily changes to insurance and reimbursement.

As a professional voyeur of healthcare, I feel confident in predicting what American healthcare will look like in 20 or 30 years. My confidence comes from my sense of the forces that will lead to the reform of the system, the forces that will restrain reform and affect the way the issue is debated by the public (as both consumers and taxpayers), physicians, employers, insurers, the healthcare industry, and opinion leaders on both the left and the right. What is impossible to predict is how quickly we will get there.

Tomorrow's Healthcare System

Eventually, I believe, we will get much closer to universal coverage, but it will come in the form of a complex, pluralistic, uniquely American system built on what we have now—not because that's the best option but because, politically, it will be the easiest to achieve.

Some predictions:

Coverage The system will cover most people but, as in many countries with universal coverage, not absolutely everyone.

Payers It will be a multipayer pluralistic system with federal and state governments, employers, and individuals all paying (a lot!). There will be group and individual insurance, with both for-profit and not-for-profit insurers and providers. There will be more mandates for employers and individuals, while some government programs (including Medicare, Medicaid, and the State Children's Health Insurance Program) will expand.

Tiers The insurance system will have multiple tiers and a modest safety net, with big differences in the quality of coverage in different tiers.

Management There will be major changes in reimbursement. Consumer choice will be emphasized—for those who can afford it. Incentives for providers will be based on new, better (but never perfect) measures of efficacy, safety, quality, and cost-effectiveness.

The new, reformed system will be even more complicated than it is now. Some parts of it will emphasize competition and the benefits of market forces, but there will still be substantial single-payer government programs.

If, after 2008, as seems likely now, we have a Democratic president and the Democrats control Congress, the ideological balance will tilt back to more emphasis on single-payer systems (but not one system) and away from market-driven systems and individual insurance markets. Democrats may be predisposed to punish the industry for its support of the Republicans over the last six years.

What Won't Happen

We will not get a national health service, the government employment of most physicians or ownership of most hospitals, or a single government health-insurance program. Politically, those would not be acceptable. We will not get anything looking remotely like the single-payer systems in Britain, Scandinavia, or Canada. But we may adopt elements of systems in Germany, the Netherlands, Australia, and Switzerland.